Most lab test safety events occur outside lab

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Mislabeled specimens, incomplete or missing labels and test report delays are identified as the top safety issues in ECRI Institute PSO’s newly released study on lab test-related safety events.

The study is based on a Deep Dive analysis of laboratory-related safety events focusing on the impact of errors in the laboratory testing process on clinical decision making.

ECRI Institute PSO found that 96% of the events were associated with processes that actually occurred outside of the laboratory. Yet, organizations often said that the events they reported originated in the laboratory.

The analysis covers events which occurred from 2011 through May 2013. More than half of the 2,420 reported events were associated with three types of events: mislabeled specimens, specimens with an incomplete or missing label, and missing or delayed results.

“Strategies to reduce diagnostic errors involving laboratory testing must entail all phases of the laboratory testing process and engage all stakeholders in that process,” said Dr Karen Zimmer, medical director, ECRI Institute PSO.

ECRI Institute PSO says the responsibility rests with everyone involved in the total testing process, from the provider who orders a laboratory test to the lab technician who processes the test order and records the test results.

“We recommend a hierarchy of error-reduction techniques to improve the total testing process and to enhance patient safety,” added Zimmer.

The Laboratory Safety PSO Deep Dive findings were published in a report available to all ECRI Institute PSO members and its partner PSO members. It reviews strategies for leadership support, standardizing and simplifying some processes, technology solutions, communication and teamwork, staff education, event reporting and analysis, performance improvement, and patient involvement.